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Name: |
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Date of Birth: |
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Email address: |
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Other preferred method of contact, address or phone number: |
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Blood Group (if known): |
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1. What do you feel that you want to achieve from this session? |
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2. What's Going on at the moment with you, emotionally, spiritually and physically? |
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3. What is your creativity and motivation like? |
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4. Energy levels? |
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5. Concentration and Short term memory? |
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6. Sleep? Do you sleep through the night? If not what times do you wake? |
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7. Do you feel refreshed when you wake up in the morning? |
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8. Do you suffer from headaches? If yes when and where in the head? What makes it better or worse? Sinuses? |
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9. Hair / Scalp / skin - do you have any dryness, dandruff, itchy scalp, eczema on your body (if so where), how do you treat it? |
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10. Lungs? Any problems with Asthma etc? do you smoke and if yes how many? |
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11. Digestion? Burping, refluxing, pain in stomach after or during eating? Cramps etc? |
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12. Bowels? - how often do you poo, does it feel complete when you do? Do you get constipated or suffer with diahhorea or Piles, bleeding, passing of mucus, passing of complete pieces of food? Anything else? |
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13. Urination? Strong smell, dark colour? |
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14. Menstruation? Problems, pmt, pain etc (especially for the guys!) |
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15. Muscles / joints - any discomfort? Where and what makes it better? |
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16. Occupation / do you work shifts? Long hours, nights etc? workaholic? When and do you relax? |
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17. Circulation - are you a Hot / Cold person? Sweats? Cold sweats at night? |
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18. |
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A) Age of your mother at birth? |
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B) What is your position in your family? |
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C) What are the yearly gaps between you and your sisters/brothers |
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D) Status of your mother in her family? |
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E) Was your birth easy, difficult? |
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19. |
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A) Anything about your mothers pregnancy with you. |
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B) Were you breast fed & vaccinated? |
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C) Any complications? |
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20. Where were you born geographically? |
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21. Health in your Infancy? Vaccines, repetitive illnesses? |
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22. What was you Childhood health like? - did you suffer with catarrh, ear/nose/throat problems, tonsilitis, sinus problems, constipation, measles etc, asthma, psorasis? Please be as detailed as possible. |
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23. Your teenage years? |
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A) Any eating disorders |
yesno |
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B) Addictions with smoking drugs or alcohol |
yesno |
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C) Age periods started |
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D) Acne? |
yesno |
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E) Did you have the BCG vaccination? |
yesno |
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24. Decades through life - any major illnesses, operations, recurring illnesses? Use of drugs, alcohol, smoking? Depression? |
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A)20's |
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B)30's |
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C)40's |
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D)50's |
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25. Family health |
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A) Mother? |
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B) Father? |
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C) Grandparents on both sides? |
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D) Siblings? |
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26. |
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A) How much water do you drink in a day (and don't lie!!!!!!) |
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B) Typical diet in a day (good and bad days!) |
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C) How much alcohol (this needs to be really honest with nothing hidden please!) |
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D) and at what times do you eat |
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E) do you chew your food and do you rush eating...standing up etc. |
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27. Are you taking any medication, drugs at the moment? (Pill / HRT, nurofen, aspirins, thyroxin etc) |
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28. Supplements, vit's, minerals? - homeopathy? Herbs? what & how many ? |
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29. How much exercise do you do? Do you attend classes for yoga or dance? Do you Run or Walk? Do you and can you relax? Do you meditate? |
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30. Anything else you feel may be relevant to your life? |
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